Crisis brewing at HRMC

Doctors, patients, nurses, ambulance drivers — even hospital board members — were unaware of a crisis brewing at Haywood Regional Medical Center that jeopardized its Medicare and Medicaid status and, as a result, the future of the hospital.

David Rice, who resigned as the hospital’s CEO Monday, has known that Medicare and Medicaid payments to the hospital could be cut off for at least two weeks. However, he and staff members aware of the potential crisis failed to alert the public, the medical community, neighboring hospitals, county leaders, or his own hospital board ahead of time.

The lack of notice left little time for anyone to develop contingency plans — whether it’s doctors canceling their surgeries, neighboring hospitals preparing for a patient overload, or EMS calling in back-up ambulance drivers to transport patients to hospitals in other counties. The medical community, county leaders and hospital board members have expressed disappointment that hospital administration was not more open, even if the chance was remote that the worst-case scenario would actually come to fruition.

County Commissioner Mary Ann Enloe said the veil of secrecy over the crisis has been “absolutely inexcusable.”

“I don’t like secrecy with anything,” Enloe said. “That is one of my biggest concerns right now, the lack of information. People are frightened. The employees are frightened. Our citizens are frightened.”

Rice hoped the hospital could avert the crisis. After first being cited with violations in late January, the hospital received a warning and was given a chance to fix the problems. Rice banked on the hospital passing subsequent inspections and decided to keep the situation in-house.

“We were so confident the data was looking so good, we thought there was no need to inform them,” Rice said. But the hospital failed its follow-up inspections, and the worst-case scenario came to fruition.

After the hospital failed its first follow-up visit, Rice received notice Feb. 13 telling him that termination of Medicare would be effective Feb. 24. Rice chose not to make the news public, however, banking on passing a second follow-up inspection. That was held on Feb. 22 — just two days before the hospital’s Medicare status was set to expire.

The hospital failed it as well. In 36 hours, the hospital would lose its Medicare status. Yet Rice again made the decision not to go public, even though the news was leaking out in the community. Rice again banked on the hospital passing yet a third follow-up inspection over the weekend. But again, the hospital failed the follow-up inspection, and both the hospital’s Medicare and Medicaid status were formally revoked.

“We didn’t think it was going to go this way,” Rice said. “If I had any idea it was going to go this way, we would have informed the medical staff we had a potential problem.”

The failure on the part of hospital administration to communicate persisted even after the hospital’s revoked status went into effect over the weekend. Doctors, neighboring hospitals and the public were left to learn what they could from the media, which wasn’t much since hospital administration was limiting interviews with reporters.

Enloe said the hospital administration should have utilized media outlets as a means of communicating with the public.

“This is about as serious a situation as a hospital could be in. The people need to know and the only way to do that is through the media,” Enloe said. “If the hospital does not understand the enormity of this, I don’t know who to get that across to them.”

How word got out

Just about everyone learned of the possible crisis when the federal government placed a legal notice in the Asheville Citizen-Times classified section Friday, Feb. 22. The notice announced that the hospital’s Medicare status would be revoked as of Sunday, Feb. 24.

Few people read the fine print of legal notices in the back section of newspapers, but a few within the medical community apparently saw it and began circulating the news. By the end of the day Friday, word had finally spread by doctors calling other doctors. There was no attempt by the hospital to formally notify doctors, however. Instead, doctors learned of the situation through the grapevine from colleagues passing around bits of accumulated information.

Dr. David Markoff, an ophthalmologist, first learned of the situation from a friend inside the hospital who read the legal notice and called him. Markoff was in a quandary. As an eye specialist, a huge portion of his patients are seniors on Medicare — including eight of his nine eye surgeries scheduled for the following Monday. When Markoff called the hospital to find out what was going on, officials told him the inspectors were coming back Sunday for a follow-up visit and hopefully the whole mess would be cleared up.

“I vacillated between calling my patients Friday or waiting to see if it was lifted,” Markoff said. He decided to wait.

Meanwhile, however, Markoff began calling other doctors to see what they had heard. Markoff ended up breaking the bad news to others, including Dr. Benny Sharpton, a surgeon. It was after 5 o’clock on Friday and Sharpton had yet to be informed by the hospital, despite having surgeries of his own scheduled for Monday morning. Sharpton decided to cancel his surgeries and called the patients himself.

“I explained to them there was a situation concerning Medicare and that the hospital would not be able to receive Medicare patients. They were unaware of the information at that time, but they took the delay well after the explanation was given to them,” Sharpton said.

Like Markoff, Sharpton wondered how things got to this point. Was trouble brewing between the hospital and Medicare for a long time, or was this a sudden and heavy-handed edict?

Sharpton said the hospital administration must have been caught off guard by the ruling or surely they would have informed doctors earlier.

“It is my opinion they, too, were surprised,” Sharpton said. “Otherwise I think they would have notified us of something that would affect our practices.”

Dr. Al Mina, another surgeon, also suspects the hospital was caught off guard and tends to blame the inspectors. The announcement ran in the paper Friday — the same day the inspectors were conducting one of their follow-up visits. Mina questioned whether the inspectors jumped the gun by running the announcement before completing the follow-up visit that, if passed, would have cleared the hospital.

Of course, the hospital didn’t pass. Markoff had to call eight of the nine patients scheduled for the following day and call off their appointment.

“Most of them had seen something in the newspaper or on TV and were wondering about that. They weren’t happy about it, but they understand I have no control over it,” Markoff said. Many of them had made accommodations for their surgery, like a daughter taking off work for the day to drive them. One patient had already paid his co-pay to the hospital.

No excuse

Dr. Eli Zaslow, a family doctor at Hazelwood Family Medicine, is not cutting Rice any slack. Rice should have told the community of the pending crisis early on, however remote the pssibility that it would actually come to pass, Zaslow said.

“Covering things up and hiding them isn’t so good. That was not the right way to do it,” said Zaslow, who was formerly an ER doctor until Rice ousted him and his partners and replaced them with a national physician staffing outfit.

“It is a reflection of the ongoing disregard by David Rice for physicians,” said Zaslow.

It is not the first time the hospital administration has been accused of such. Rice has been under fire from the medical community on and off for four years for what many describe as a cavalier attitude toward doctors.

The charge was first leveled against Rice four years ago following a total collapse of orthopedics — a rift between doctors and hospital administration that left the county without a single doctor who could fix a broken bone. That crisis was shortly followed by a mass exodus of the hospital’s anesthesiologists, who claimed they were treated like a commodity and not listened to.

The relationship between the medical community and hospital administration reached a new low in late 2006 when the hospital ousted a long-time group of ER doctors and replaced them with a national physician staffing outfit. Rice led the charge against the ER doctors and convinced the hospital board to get rid of them. The controversy was largely seen as a power struggle between Rice and a couple of the ER doctors known for speaking out.

The medical community pleaded with Rice and the hospital board not to oust the ER doctors. When the hospital did so anyway, doctors felt ignored, betrayed and belittled that their wishes were not taken into account.

That’s why Zaslow said he wasn’t surprised by the lack of communication with the medical community.

When Rice spoke to meeting of the county’s doctors Monday night following his resignation announcement, that was the only area where he offered an apology or cited a personal shortcoming.

“There are times when I failed at communication. I regret that,” Rice said.

Board left in the dark

Doctors aren’t the only ones who are disappointed they weren’t told about the pending crisis. Board members also felt that way.

“I feel there should have been some kind of notification to the board,” said Mark Clasby, a hospital board member and the county economic development director. “I think there should have been a contingency plan instead of trying to figure something out at the last minute.”

Steve Sorrells, another hospital board member, found out through the grapevine as well. Once he learned about it, he wanted to know more, but at the same time knew Rice had more important things to worry about. Sorrells finally broke down on Saturday evening and called Rice for what he described as a two-minute conversation.

“I told David, ‘You get whoever it takes in there to fix this problem, period. I don’t care where they have to come from. Get them in there and get it fixed,’” Sorrells said.

In an interview Sunday, Sorrells assumed hospital officials were as shocked as the board.

“From what I’ve been told, they are all totally shocked. Maybe they shouldn’t have been, but we will find out,” Sorrells said. “First we are going to get this hospital back open and then we are going to find out what happened.”

The next day, Rice resigned.

EMS wasn’t notified

Another group left in the lurch: county ambulance services. If Medicare patients could not be accepted at Haywood Regional, ambulance drivers would be spending inordinate amounts of time driving patients to hospitals in neighboring counties instead. That could leave the county with a shortage of ambulance drivers, making it necessary for EMS to come up with a contingency plan of their own.

But once again, the hospital failed to notify an important stakeholder. Haywood County Manager David Cotton found out about the possible crisis late Friday afternoon when someone alerted him to the public notice in the Asheville Citizen-Times. Within minutes, Cotton had called together the county’s EMS staff to talk about the impact the termination would have on area ambulance transports.

“We put a tentative plan in place because we still didn’t know all of the details Friday afternoon, but by Saturday at noon we decided to implement our plan,” he said.

Cotton didn’t find out that Medicaid patients would be added into the mix until a reporter informed him at 1 p.m. Monday.

Commissioners have questions

County commissioners were also unaware of the problem, which Commissioner Mary Ann Enloe found unacceptable.

“As a private citizen, I would have liked advance notice, but as a county official, absolutely,” Enloe said.

While today the hospital is an independent non-profit, it’s control is still tied to the county from its old days as a county hospital. The county commissioners appoint the hospital board members, for example.

Other commissioners did not seem as concerned as Enloe about the hospitals failure to communicate with the county or with the public — although they did all have their own stories about how they heard the news.

The news of the Medicare termination reached Commissioner Chairman Larry Ammons through the grapevine when he happened to stop by the county offices to collect his mail Friday afternoon. An EMS driver who took a patient to the hospital that day saw people at the hospital gathered around reading the public notice in the Asheville Citizen-Times. The driver rushed a copy of the paper back to Assistant County Manager Marty Stamey, and the office was abuzz by the time Ammons arrived.

Commissioner Skeeter Curtis, meanwhile, got a call from someone else who had seen the now-infamous legal notice.

“Someone called me and said, did you see the Friday legal section of the paper, and I said no. They said, well, you need to go read it. So I went to the paper and read that legal notice. I was very surprised, especially after the hospital had just received so many awards. I had no idea, and I still don’t have any idea what the story is,” Curtis said.